Updates to 2012 Standards

View Appendix A of the 2013 Handbook to preview changes since the 2012 publication release.

Based on feedback from CMS, we have made changes to the 2012 AAAHC/CMS crosswalk. Major changes include:

• Organizations no longer have to adhere to a specified list of emergency equipment. Instead, organizations must craft an appropriate emergency equipment plan based on the procedures performed and population served. The emergency equipment must be immediately available for use during emergency situations.
• In May 2009, CMS incorporated Infection Control as a condition-level requirement. At that time, CMS standards related to infection control were included under the condition for Physical Environment. Earlier this year, CMS eliminated this duplication of standards by removing these infection control-related standards from the Physical Environment condition and exclusively maintaining infection control-related standards under the Infection Control condition for coverage.

The complete revised crosswalk can be viewed here.

All changes became effective July 16, 2012 and will be applied on all Medicare deemed status surveys after this date.

Because an ASC that is seeking a Medicare deemed status survey must be open and operational, CMS has advised us to revise our policies regarding the Early Option Survey/Initial Medicare Deemed Status Survey. These policy changes (underlined below) will apply to ASCs that submit an application for an Early Option Survey/Initial Medicare Deemed Status Survey on or after July 1, 2012.

The changes represent updates to policies found in the 2012 Accreditation Handbook Including Medicare Requirements for Ambulatory Surgery Centers (ASCs), page 12:

Types of Surveys

The AAAHC’s early option survey (EOS) is for ASCs that are newly constructed, operational, and actively providing surgical procedures to adequately demonstrate compliance with AAAHC accreditation requirements including Medicare requirements. Some ASCs may require accreditation for third-party reimbursement, and a six-month wait for a survey would entail financial hardship; or they may have been providing services for less than six months and are seeking AAAHC accreditation and Medicare deemed status for the first time.

When an EOS is requested, the ASC must provide evidence of the following with its Application for Survey:

• The date the ASC is open and operational and actively providing surgical procedures to adequately demonstrate compliance with AAAHC accreditation requirements including Medicare requirements.

An EOS is conducted during the ninety (90) day survey window on an unannounced basis after the ASC has opened. A minimum of ten medical records must be available for review. The names of the surveyors are not disclosed prior to the survey. The surveyors will observe a surgical procedure during the survey.

Please make note of the following change in your 2012 Accreditation Handbook Including Medicare Requirements for Ambulatory Surgery Centers (ASCs):

Addendum to correct an omission on page 46 under "Additional Medicare Requirements" 

4.K-MS(3) OR 4.K-MS(4)

CMS requires Medicare Certified ASCs to have either

4.K-MS (3) ……a written transfer agreement with a hospital that meets the requirements of 4.K-MS (2)

OR

4.K-MS (4) ……ensure all physicians performing surgery in the ASC have admitting privileges at a hospital that meets the requirements of 4.K-MS (2) (page 46).

All AAAHC/Medicare Deemed Status accredited organizations and those seeking Medicare Deemed Status accreditation from AAAHC are being notified of this correction.